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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD "t a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM F—] 2 INTERIM PERMIT f74 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE [ TI NNK REMOVED' O C9 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A OWNER'S TANK 1.D. _ B. MANUFACTURED BY: (J(L/kN OU.J C. DATE INSTALLED(MO/DAYNEAR) ,J,n. r 1/,7/11 D. TANK CAPACITY IN GALLONS: / Bm J' II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. �/ A 52-1-MOTOR VEHICLE FUEL ❑ 4 OIL B. C. '�ey�p GUWi UNLEADED Q 3 DIESEL ❑ 6 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT EL 11c Al DGRADIUME UNLEADED ❑ 5 JET SFUEL ❑ 8 M85 ANOI ❑ 3 CHEMICALPRODUCT O 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER(DESCRIBE N ITEM D.BELOW) D. IF(AA)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX DME)E A. TYPE OF D 1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWNN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO..IL D.EXTERIOR ❑ 1 POLYETHYLENE WRAP [j 2 COATING ❑ 3 WRAP E:] 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN O 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENTJHSTALLED(YEAR) OVERFILL PEY RENION EQUIPMENT INSTALLED(YEAR) f DROP TUBE YES NO STRIKER PLATE YES_✓ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDCCU"*UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A&,2 PRESSURE A U 3 GRAVITY A U 4 PLEXIBLEPIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 AL INUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U LVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ET Wawnru ME IEuc 2 uxE TwlrtCd K% 3 MM=51RIERGiIILLL 4 EU:CINOMC UNE 5 AWOM M PUW ❑ OEIEOTOR STNG MO MNG ❑ MIX WrEMM ❑ EHUmOWN 99 OTHER V.TANK LEAK DETECTION ❑ NUAL 1 VISUAL CHECK 171 2 RECO CILATIONINVENTORY ❑ 3 MONIITORING VAOZE ❑ 4 GAUGING TANK AUTOMATI ❑5 MONITORINGOUNDWATER ❑6 TTEESTINGTANK ❑ UAL 7 MONITORING INTERSTITIAL O 8 SIR ❑ 9 WEEKLTANK AUG MANUAL ❑10 MONTHLYTESTING TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MO/DAY/YR) `_ 2.ESTIMATED OUANTTTY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NOgall THIS FORM HAS BEEN CO P ED UNDER PE LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNE AM 1, A DATE (PRINTED461GNA ` s v (� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m I 11 -7161111Q PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUSTSHOULD BE ACCOMPANIED BY AIPLOT FIWLEFORM A,UNLESS A THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THRENT FORM A HAS 13EEN FILED. IWROUND STORAGEUST BE ED FOR NS.THIS FORM TANK REGULATIONS FORM B (6-95) .�